|
EPINEPHrine 1 mg/mL 30ml Inj MDV [VDMC]
|
Facility
|
IP
|
$645.48
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386241
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$451.84 |
| Max. Negotiated Rate |
$580.93 |
| Rate for Payer: Aetna of IA Commercial |
$580.93
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$580.93
|
| Rate for Payer: Cash Price |
$516.38
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$484.11
|
| Rate for Payer: Medical Associates Commercial |
$484.11
|
| Rate for Payer: Midlands Choice Commercial |
$451.84
|
| Rate for Payer: United Healthcare Commercial |
$580.93
|
|
|
EPINEPHrine Emergency syringe 0.1 mg/mL 10ml Inj SDV [VDMC]
|
Facility
|
OP
|
$54.96
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$27.47 |
| Max. Negotiated Rate |
$49.46 |
| Rate for Payer: Aetna of IA Commercial |
$49.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.46
|
| Rate for Payer: Aetna of IA Medicare |
$31.33
|
| Rate for Payer: Amerigroup Medicaid |
$27.74
|
| Rate for Payer: Amerigroup Medicare |
$27.75
|
| Rate for Payer: Cash Price |
$43.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.22
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$27.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$27.47
|
| Rate for Payer: Medical Associates Commercial |
$41.22
|
| Rate for Payer: Medical Associates Managed Medicare |
$27.48
|
| Rate for Payer: Midlands Choice Commercial |
$38.47
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$27.89
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$27.88
|
| Rate for Payer: Oscar Health of IA Commercial |
$41.22
|
| Rate for Payer: Partners Health Alliance Commercial |
$41.22
|
| Rate for Payer: United Healthcare Commercial |
$49.46
|
| Rate for Payer: United Healthcare Managed Medicare |
$32.43
|
|
|
EPINEPHrine Emergency syringe 0.1 mg/mL 10ml Inj SDV [VDMC]
|
Facility
|
IP
|
$54.96
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386040
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$38.47 |
| Max. Negotiated Rate |
$49.46 |
| Rate for Payer: Aetna of IA Commercial |
$49.46
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$49.46
|
| Rate for Payer: Cash Price |
$43.96
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$41.22
|
| Rate for Payer: Medical Associates Commercial |
$41.22
|
| Rate for Payer: Midlands Choice Commercial |
$38.47
|
| Rate for Payer: United Healthcare Commercial |
$49.46
|
|
|
EPINEPHrine ( Eye Surgery )1 mg/mL 0.3ml Inj Sol [VDMC]
|
Facility
|
IP
|
$104.97
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10607748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$73.48 |
| Max. Negotiated Rate |
$94.47 |
| Rate for Payer: Aetna of IA Commercial |
$94.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.47
|
| Rate for Payer: Cash Price |
$83.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.73
|
| Rate for Payer: Medical Associates Commercial |
$78.73
|
| Rate for Payer: Midlands Choice Commercial |
$73.48
|
| Rate for Payer: United Healthcare Commercial |
$94.47
|
|
|
EPINEPHrine ( Eye Surgery )1 mg/mL 0.3ml Inj Sol [VDMC]
|
Facility
|
OP
|
$104.97
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10607748
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$52.46 |
| Max. Negotiated Rate |
$94.47 |
| Rate for Payer: Aetna of IA Commercial |
$94.47
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$94.47
|
| Rate for Payer: Aetna of IA Medicare |
$59.83
|
| Rate for Payer: Amerigroup Medicaid |
$52.98
|
| Rate for Payer: Amerigroup Medicare |
$53.01
|
| Rate for Payer: Cash Price |
$83.97
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$78.73
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$52.48
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$52.46
|
| Rate for Payer: Medical Associates Commercial |
$78.73
|
| Rate for Payer: Medical Associates Managed Medicare |
$52.48
|
| Rate for Payer: Midlands Choice Commercial |
$73.48
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$53.27
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$53.24
|
| Rate for Payer: Oscar Health of IA Commercial |
$78.73
|
| Rate for Payer: Partners Health Alliance Commercial |
$78.73
|
| Rate for Payer: United Healthcare Commercial |
$94.47
|
| Rate for Payer: United Healthcare Managed Medicare |
$61.93
|
|
|
EPINEPHrine (PEN JR) 0.15 mg Inj kit SDV [VDMC]
|
Facility
|
IP
|
$545.14
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$381.60 |
| Max. Negotiated Rate |
$490.63 |
| Rate for Payer: Aetna of IA Commercial |
$490.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$490.63
|
| Rate for Payer: Cash Price |
$436.11
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$408.86
|
| Rate for Payer: Medical Associates Commercial |
$408.86
|
| Rate for Payer: Midlands Choice Commercial |
$381.60
|
| Rate for Payer: United Healthcare Commercial |
$490.63
|
|
|
EPINEPHrine (PEN JR) 0.15 mg Inj kit SDV [VDMC]
|
Facility
|
OP
|
$545.14
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
10386111
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$272.46 |
| Max. Negotiated Rate |
$490.63 |
| Rate for Payer: Aetna of IA Commercial |
$490.63
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$490.63
|
| Rate for Payer: Aetna of IA Medicare |
$310.73
|
| Rate for Payer: Amerigroup Medicaid |
$275.13
|
| Rate for Payer: Amerigroup Medicare |
$275.30
|
| Rate for Payer: Cash Price |
$436.11
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$408.86
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$272.57
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$272.46
|
| Rate for Payer: Medical Associates Commercial |
$408.86
|
| Rate for Payer: Medical Associates Managed Medicare |
$272.57
|
| Rate for Payer: Midlands Choice Commercial |
$381.60
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$276.66
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$276.50
|
| Rate for Payer: Oscar Health of IA Commercial |
$408.86
|
| Rate for Payer: Partners Health Alliance Commercial |
$408.86
|
| Rate for Payer: United Healthcare Commercial |
$490.63
|
| Rate for Payer: United Healthcare Managed Medicare |
$321.63
|
|
|
Epistaxis With MCC
|
Facility
|
IP
|
$13,041.20
|
|
|
Service Code
|
MS-DRG 150
|
| Hospital Charge Code |
30
|
| Min. Negotiated Rate |
$12,852.19 |
| Max. Negotiated Rate |
$13,041.20 |
| Rate for Payer: Amerigroup Medicaid |
$12,978.20
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12,852.19
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$13,041.20
|
|
|
Epistaxis Without MCC
|
Facility
|
IP
|
$3,987.16
|
|
|
Service Code
|
MS-DRG 151
|
| Hospital Charge Code |
31
|
| Min. Negotiated Rate |
$3,929.38 |
| Max. Negotiated Rate |
$3,987.16 |
| Rate for Payer: Amerigroup Medicaid |
$3,967.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$3,929.38
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$3,987.16
|
|
|
epoetin alfa 10,000 units/mL 1ml SDV preservative-free Sol [VDMC]
|
Facility
|
IP
|
$672.06
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
17637210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$470.44 |
| Max. Negotiated Rate |
$604.85 |
| Rate for Payer: Aetna of IA Commercial |
$604.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$604.85
|
| Rate for Payer: Cash Price |
$537.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$504.04
|
| Rate for Payer: Medical Associates Commercial |
$504.04
|
| Rate for Payer: Midlands Choice Commercial |
$470.44
|
| Rate for Payer: United Healthcare Commercial |
$604.85
|
|
|
epoetin alfa 10,000 units/mL 1ml SDV preservative-free Sol [VDMC]
|
Facility
|
OP
|
$672.06
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
17637210
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$335.90 |
| Max. Negotiated Rate |
$604.85 |
| Rate for Payer: Aetna of IA Commercial |
$604.85
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$604.85
|
| Rate for Payer: Aetna of IA Medicare |
$383.07
|
| Rate for Payer: Amerigroup Medicaid |
$339.19
|
| Rate for Payer: Amerigroup Medicare |
$339.39
|
| Rate for Payer: Cash Price |
$537.65
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$504.04
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$336.03
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$335.90
|
| Rate for Payer: Medical Associates Commercial |
$504.04
|
| Rate for Payer: Medical Associates Managed Medicare |
$336.03
|
| Rate for Payer: Midlands Choice Commercial |
$470.44
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$341.07
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$340.87
|
| Rate for Payer: Oscar Health of IA Commercial |
$504.04
|
| Rate for Payer: Partners Health Alliance Commercial |
$504.04
|
| Rate for Payer: United Healthcare Commercial |
$604.85
|
| Rate for Payer: United Healthcare Managed Medicare |
$396.52
|
|
|
epoetin alfa 2000 units/mL PF SDV [VDMC]
|
Facility
|
OP
|
$148.03
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
15937907
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$133.23 |
| Rate for Payer: Aetna of IA Commercial |
$133.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.23
|
| Rate for Payer: Aetna of IA Medicare |
$84.38
|
| Rate for Payer: Amerigroup Medicaid |
$74.71
|
| Rate for Payer: Amerigroup Medicare |
$74.76
|
| Rate for Payer: Cash Price |
$118.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.02
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$74.02
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$73.99
|
| Rate for Payer: Medical Associates Commercial |
$111.02
|
| Rate for Payer: Medical Associates Managed Medicare |
$74.02
|
| Rate for Payer: Midlands Choice Commercial |
$103.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$75.13
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$75.08
|
| Rate for Payer: Oscar Health of IA Commercial |
$111.02
|
| Rate for Payer: Partners Health Alliance Commercial |
$111.02
|
| Rate for Payer: United Healthcare Commercial |
$133.23
|
| Rate for Payer: United Healthcare Managed Medicare |
$87.34
|
|
|
epoetin alfa 2000 units/mL PF SDV [VDMC]
|
Facility
|
IP
|
$148.03
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
15937907
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$103.62 |
| Max. Negotiated Rate |
$133.23 |
| Rate for Payer: Aetna of IA Commercial |
$133.23
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$133.23
|
| Rate for Payer: Cash Price |
$118.43
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$111.02
|
| Rate for Payer: Medical Associates Commercial |
$111.02
|
| Rate for Payer: Midlands Choice Commercial |
$103.62
|
| Rate for Payer: United Healthcare Commercial |
$133.23
|
|
|
epoetin alfa-epbx 10,000 units/mL 1ml SDV preservative-free Sol[VDMC]
|
Facility
|
IP
|
$373.35
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
24628846
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$261.34 |
| Max. Negotiated Rate |
$336.02 |
| Rate for Payer: Aetna of IA Commercial |
$336.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.02
|
| Rate for Payer: Cash Price |
$298.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.01
|
| Rate for Payer: Medical Associates Commercial |
$280.01
|
| Rate for Payer: Midlands Choice Commercial |
$261.34
|
| Rate for Payer: United Healthcare Commercial |
$336.02
|
|
|
epoetin alfa-epbx 10,000 units/mL 1ml SDV preservative-free Sol[VDMC]
|
Facility
|
OP
|
$373.35
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
24628846
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$186.60 |
| Max. Negotiated Rate |
$336.02 |
| Rate for Payer: Aetna of IA Commercial |
$336.02
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$336.02
|
| Rate for Payer: Aetna of IA Medicare |
$212.81
|
| Rate for Payer: Amerigroup Medicaid |
$188.43
|
| Rate for Payer: Amerigroup Medicare |
$188.54
|
| Rate for Payer: Cash Price |
$298.68
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$280.01
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$186.68
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$186.60
|
| Rate for Payer: Medical Associates Commercial |
$280.01
|
| Rate for Payer: Medical Associates Managed Medicare |
$186.68
|
| Rate for Payer: Midlands Choice Commercial |
$261.34
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$189.48
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$189.36
|
| Rate for Payer: Oscar Health of IA Commercial |
$280.01
|
| Rate for Payer: Partners Health Alliance Commercial |
$280.01
|
| Rate for Payer: United Healthcare Commercial |
$336.02
|
| Rate for Payer: United Healthcare Managed Medicare |
$220.28
|
|
|
Epstein Barr Virus Profile DMCL
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
8519173
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.12 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Aetna of IA Medicare |
$64.98
|
| Rate for Payer: Amerigroup Medicaid |
$57.54
|
| Rate for Payer: Amerigroup Medicare |
$57.57
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$57.00
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$56.98
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Medical Associates Managed Medicare |
$57.00
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$57.86
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$57.82
|
| Rate for Payer: Oscar Health of IA Commercial |
$85.50
|
| Rate for Payer: Partners Health Alliance Commercial |
$85.50
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
| Rate for Payer: United Healthcare Managed Medicare |
$67.26
|
| Rate for Payer: Wellmark IA HMO |
$47.12
|
| Rate for Payer: Wellmark IA PPO |
$51.83
|
|
|
Epstein Barr Virus Profile DMCL
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
8519173
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna of IA Commercial |
$102.60
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$102.60
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$85.50
|
| Rate for Payer: Medical Associates Commercial |
$85.50
|
| Rate for Payer: Midlands Choice Commercial |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$102.60
|
|
|
ergocalciferol 50,000 intl units Cap [VDMC]
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10386848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of IA Commercial |
$1.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.35
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Midlands Choice Commercial |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
|
|
ergocalciferol 50,000 intl units Cap [VDMC]
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10386848
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna of IA Commercial |
$1.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$1.35
|
| Rate for Payer: Aetna of IA Medicare |
$0.86
|
| Rate for Payer: Amerigroup Medicaid |
$0.76
|
| Rate for Payer: Amerigroup Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$1.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$0.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$0.75
|
| Rate for Payer: Medical Associates Commercial |
$1.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$0.75
|
| Rate for Payer: Midlands Choice Commercial |
$1.05
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$0.76
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$0.76
|
| Rate for Payer: Oscar Health of IA Commercial |
$1.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.35
|
| Rate for Payer: United Healthcare Managed Medicare |
$0.89
|
|
|
ertapenem 1 g Inj SDV [VDMC]
|
Facility
|
IP
|
$111.50
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
10386917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$78.05 |
| Max. Negotiated Rate |
$100.35 |
| Rate for Payer: Aetna of IA Commercial |
$100.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.35
|
| Rate for Payer: Cash Price |
$89.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.62
|
| Rate for Payer: Medical Associates Commercial |
$83.62
|
| Rate for Payer: Midlands Choice Commercial |
$78.05
|
| Rate for Payer: United Healthcare Commercial |
$100.35
|
|
|
ertapenem 1 g Inj SDV [VDMC]
|
Facility
|
OP
|
$111.50
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
10386917
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$55.73 |
| Max. Negotiated Rate |
$100.35 |
| Rate for Payer: Aetna of IA Commercial |
$100.35
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$100.35
|
| Rate for Payer: Aetna of IA Medicare |
$63.56
|
| Rate for Payer: Amerigroup Medicaid |
$56.27
|
| Rate for Payer: Amerigroup Medicare |
$56.31
|
| Rate for Payer: Cash Price |
$89.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$83.62
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$55.75
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$55.73
|
| Rate for Payer: Medical Associates Commercial |
$83.62
|
| Rate for Payer: Medical Associates Managed Medicare |
$55.75
|
| Rate for Payer: Midlands Choice Commercial |
$78.05
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$56.59
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$56.55
|
| Rate for Payer: Oscar Health of IA Commercial |
$83.62
|
| Rate for Payer: Partners Health Alliance Commercial |
$83.62
|
| Rate for Payer: United Healthcare Commercial |
$100.35
|
| Rate for Payer: United Healthcare Managed Medicare |
$65.78
|
|
|
erythromycin ophthalmic 0.5% Oint. 3.5gm [VDMC]
|
Facility
|
OP
|
$49.80
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
18197658
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$24.89 |
| Max. Negotiated Rate |
$44.82 |
| Rate for Payer: Aetna of IA Commercial |
$44.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.82
|
| Rate for Payer: Aetna of IA Medicare |
$28.39
|
| Rate for Payer: Amerigroup Medicaid |
$25.13
|
| Rate for Payer: Amerigroup Medicare |
$25.15
|
| Rate for Payer: Cash Price |
$39.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.35
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$24.90
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$24.89
|
| Rate for Payer: Medical Associates Commercial |
$37.35
|
| Rate for Payer: Medical Associates Managed Medicare |
$24.90
|
| Rate for Payer: Midlands Choice Commercial |
$34.86
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$25.27
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$25.26
|
| Rate for Payer: Oscar Health of IA Commercial |
$37.35
|
| Rate for Payer: Partners Health Alliance Commercial |
$37.35
|
| Rate for Payer: United Healthcare Commercial |
$44.82
|
| Rate for Payer: United Healthcare Managed Medicare |
$29.38
|
|
|
erythromycin ophthalmic 0.5% Oint. 3.5gm [VDMC]
|
Facility
|
IP
|
$49.80
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
18197658
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$34.86 |
| Max. Negotiated Rate |
$44.82 |
| Rate for Payer: Aetna of IA Commercial |
$44.82
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$44.82
|
| Rate for Payer: Cash Price |
$39.84
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$37.35
|
| Rate for Payer: Medical Associates Commercial |
$37.35
|
| Rate for Payer: Midlands Choice Commercial |
$34.86
|
| Rate for Payer: United Healthcare Commercial |
$44.82
|
|
|
Erythropoietin Level DMCL
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
8037840
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$125.30 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
|
|
Erythropoietin Level DMCL
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
8037840
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$161.10 |
| Rate for Payer: Aetna of IA Commercial |
$161.10
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$161.10
|
| Rate for Payer: Aetna of IA Medicare |
$102.03
|
| Rate for Payer: Amerigroup Medicaid |
$90.34
|
| Rate for Payer: Amerigroup Medicare |
$90.40
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Cash Price |
$143.20
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$134.25
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$89.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$89.46
|
| Rate for Payer: Medical Associates Commercial |
$134.25
|
| Rate for Payer: Medical Associates Managed Medicare |
$89.50
|
| Rate for Payer: Midlands Choice Commercial |
$125.30
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$90.84
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$90.79
|
| Rate for Payer: Oscar Health of IA Commercial |
$134.25
|
| Rate for Payer: Partners Health Alliance Commercial |
$134.25
|
| Rate for Payer: United Healthcare Commercial |
$161.10
|
| Rate for Payer: United Healthcare Managed Medicare |
$105.61
|
| Rate for Payer: Wellmark IA HMO |
$45.88
|
| Rate for Payer: Wellmark IA PPO |
$50.47
|
|
